Provider Demographics
NPI:1962404632
Name:RUSK, GARY DALE (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:DALE
Last Name:RUSK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3903 S 7TH ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5710
Practice Address - Country:US
Practice Address - Phone:812-232-2100
Practice Address - Fax:812-232-1980
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039496174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200089010AMedicaid
INF75842Medicare UPIN